Effects of a Mindfulness-Based Intervention on Distress, Weight Gain, and Glucose Control for Pregnant Low-Income Women: A Quasi-Experimental Trial Using the ORBIT Model.

BACKGROUND: Stress can lead to excessive weight gain. Mindfulness-based stress reduction that incorporates mindful eating shows promise for reducing stress, overeating, and improving glucose control. No interventions have tested mindfulness training with a focus on healthy eating and weight gain during pregnancy, a period of common excessive weight gain. Here, we test the effectiveness of such an intervention, the Mindful Moms Training (MMT), on perceived stress, eating behaviors, and gestational weight gain in a high-risk sample of low income women with overweight/obesity. METHOD: We conducted a quasi-experimental study assigning 115 pregnant women to MMT for 8 weeks and comparing them to 105 sociodemographically and weight equivalent pregnant women receiving treatment as usual. Our main outcomes included weight gain (primary outcome), perceived stress, and depression. RESULTS: Women in MMT showed significant reductions in perceived stress (ß = - 0.16) and depressive symptoms (ß = - 0.21) compared to the treatment as usual (TAU) control group. Consistent with national norms, the majority of women (68%) gained excessive weight according to Institute of Medicine weight-gain categories, regardless of group. Slightly more women in the MMT group gained below the recommendation. Among secondary outcomes, women in MMT reported increased physical activity (ß = 0.26) and had lower glucose post-oral glucose tolerance test (ß = - 0.23), being 66% less likely to have impaired glucose tolerance, compared to the TAU group. CONCLUSION: A short-term intervention led to significant improvements in stress, and showed promise for preventing glucose intolerance. However, the majority of women gained excessive weight. A longer more intensive intervention may be needed for this high-risk population. Clinical Trials.gov #NCT01307683.

Novel Interventions to Reduce Stress and Overeating in Overweight Pregnant Women: A Feasibility Study.

Background High stress and depression during pregnancy are risk factors for worsened health trajectories for both mother and offspring. This is also true for pre-pregnancy obesity and excessive gestational weight gain. Reducing stress and depression may be one path to prevent excessive caloric intake and gestational weight gain. Study Purpose We tested the feasibility of two novel interventions aimed at reducing stress and overeating during pregnancy. Reflecting different theoretical underpinnings, the interventions target different mechanisms. Mindful Moms Training (MMT) uses mindfulness to improve awareness and acceptance of experiences and promote conscious rather than automatic behavior choices. Emotional Brain Training (EBT) uses active coping to change perceptions of negative experience and promote positive affective states. Methods Forty-six overweight/obese low-income women were assigned to either MMT (n = 24) or EBT (n = 22) for an 8-week feasibility study. Pre-post changes in perceived stress, eating and presumed mechanisms were assessed. Results Women reported high levels of stress at baseline. Both interventions were well attended and demonstrated clinically significant pre-post reductions in stress, depressive symptoms, and improved eating behaviors. MMT significantly decreased experiential avoidance, whereas EBT significantly increased positive reappraisal; these changes were marginally significantly different by group. Conclusions This feasibility study found that both interventions promoted meaningful reductions in stress and depressive symptoms and improved reported eating behaviors in a high-risk group of pregnant women. Each intervention has a potentially different pathway-acceptance for MMT and reappraisal for EBT. Larger studies are needed to test efficacy on longer term reductions in stress and overeating.

A comparison of measured and calculated free 25(OH) vitamin D levels in clinical populations.

OBJECTIVE: Our goal was to compare direct quantitation of circulating free 25-hydroxyvitamin D (25(OH)D)levels to calculated free 25(OH)D levels and their relationships to intact PTH (iPTH), a biomarker of 25(OH)D effect, in humans with a range of clinical conditions. PATIENTS AND METHODS: Serum samples and clinical data were collected from 155 people: 111 without cirrhosis or pregnancy (comparison group), 24 cirrhotic patients with albumin <2.9 g/dL, and 20 pregnant women (second and third trimester). Total 25(OH)D (LC/MS/MS), free 25(OH)D (immunoassay), vitamin D binding protein (DBP) (immunoassay), albumin, and iPTH (immunoassay) were measured. RESULTS: Total 25(OH)D, DBP, and albumin were lowest in patients with cirrhosis, but measured free 25(OH)D was highest in this group (P < .001). DBP was highest in pregnant women (P < .001), but measured free 25(OH)D did not differ from the comparison group. Calculated free 25(OH)D was positively correlated with measured free 25(OH)D (P < .0001) but explained only 13% of the variability with calculated values higher than measured. African Americans had lower DBP than other ethnic populations within all clinical groups (P < .03), and differences between measured and calculated free 25(OH)D were greatest in African Americans (P < .001). Measured free 25(OH)D was correlated with total 25(OH)D (P < .0001; r(2) = 0.51), but calculated free 25(OH)D was not. Similarly, both measured free 25(OH)D (P < .02) and total 25(OH)D (P < .05) were correlated with iPTH, but calculated free 25(OH)D was not. CONCLUSIONS: Calculated free 25(OH)D levels varied considerably from direct measurements of free 25(OH)D with discrepancies greatest in the data for African Americans. Differences in DBP binding affinity likely contributed to estimation errors between the races. Directly measured free 25(OH)D concentrations were related to iPTH, but calculated estimates were not. Current algorithms to calculate free 25(OH)D may not be accurate. Further evaluation of directly measured free 25(OH)D levels to determine its role in research and clinical management of patients is needed.

Variability in free 25(OH) vitamin D levels in clinical populations.

UNLABELLED: Our goal was to determine total and directly measured free 25-hydroxy vitamin D (25(OH)D) serum levels in humans with a range of 25(OH)D levels and clinical conditions associated with low and high vitamin D binding protein levels. Serum samples and clinical data were collected from 106 subjects: 62 without cirrhosis or pregnancy, 24 cirrhotic patients with albumin <2.9g/dL, and 20 pregnant women. Total 25(OH)D (LC/MS/MS) and "free" 25(OH)D (immunoassay) were measured. Total 25(OH)D was significantly lower in liver disease patients but free 25(OH)D concentrations were significantly higher in this group (p<.001). Neither total nor free 25(OH)D concentrations were significantly different in pregnant women vs. the comparator group. There were significant direct positive relationships between free 25(OH)D and total 25(OH)D concentrations for the entire dataset and for each group (p<.0001), however slopes of relationships differed in the cirrhotic group compared to pregnant women or the comparator group. In cirrhotics: y (free 25(OH)D)=2.52+0.29×X(total 25 (OH)D), r(2)=.51, p<.001; y=1.45+0.09×X; r(2)=.77, p<.0001 for pregnant women; and y=1.11+0.12×X; r(2)=.72, p<.0001 for the comparator group). CONCLUSIONS: directly measured free 25(OH)D serum concentrations and relationships between total and free 25(OH)D vary with clinical conditions, and may differ from those predicted by indirect estimation methods. This article is part of a Special Issue entitled 'Vitamin D Workshop'.

Pre-pregnancy and pregnancy-related factors and the risk of excessive or inadequate gestational weight gain.

OBJECTIVE: Gestational weight gain consistent with the Institute of Medicine's recommendations is associated with better maternal and infant outcomes. The objective was to quantify the effect of pre-pregnancy factors, pregnancy-related health conditions, and modifiable pregnancy factors on the risks of inadequate and excessive gestational weight gain. METHOD: A longitudinal cohort of pregnant women (N=1100) who completed questions about diet and weight gain during pregnancy and delivered a singleton, full-term infant. RESULTS: Gestational weight gain was inadequate for 14% and excessive for 53%. Pre-pregnancy factors contributed 74% to excessive gain, substantially more than pregnancy-related health conditions (15%) and modifiable pregnancy factors (11%). Pre-pregnancy factors, pregnancy-related health conditions, and modifiable pregnancy factors contributed fairly equally to the risk of inadequate gain. CONCLUSION: Interventions to prevent excessive gestational gain may need to start before pregnancy. Women at risk for inadequate gain would also benefit from interventions directed toward modifiable factors during pregnancy.

Risk factors and obstetric complications associated with macrosomia.

OBJECTIVE: Macrosomia is associated with adverse maternal outcomes. The objective of this study was to characterize the epidemiology of macrosomia and related maternal complications. METHOD: Live births (146,526) were identified between 1995 and 1999 in the Kaiser Permanente Medical Care Program's Northern California Region (KPMCP NCR) database. Bivariate and multivariate analyses were performed for risk factors and complications associated with macrosomia (birth weight >4500 g). RESULT: Male infant sex, multiparity, maternal age 30-40, white race, diabetes, and gestational age >41 weeks were associated with macrosomia (p<0.001). In bivariate and multivariate analyses, macrosomia was associated with higher rates of cesarean birth, chorioamnionitis, shoulder dystocia, fourth-degree perineal lacerations, postpartum hemorrhage, and prolonged hospital stay (p<0.01). CONCLUSION: Macrosomia was associated with adverse maternal outcomes in this cohort. More research is needed to determine how to prevent complications related to excessive birth weight.

Menopause: social expectations, women's realities.

The experience of menopause, and the ramifications of that experience for psychiatric treatment, is significantly shaped by social and historical context and by the implicit and explicit expectations they arouse in women. American society is heavily youth-oriented. Although in fact many women experience this time as one of liberation and self-actualization, society views them as bereft of their families and devoid of sexual interest. Their expectations for their social roles at this time of life may not comport with those of their children. The emphasis on hormone treatment, incorrectly termed "replacement," has exacerbated women's fears of aging.

Safety of peripheral intravenous catheters in children.

OBJECTIVES: To determine the overall and per-day risk of complications of short peripheral intravenous (PIV) catheters placed for indefinite periods. DESIGN: During 5 months, general pediatric patients receiving intravenous therapy through short PIV catheters were monitored. Patient and catheter characteristics were recorded, complications were noted, and rolled semiquantitative cultures of removed catheters were performed. Major endpoints were infection and phlebitis. Per-day risk of complications and catheter colonization (>15 colony-forming units) were calculated. SETTING: University children's hospital. PATIENTS: General pediatric ward inpatients with PIV. RESULTS: We studied 642 Teflon catheters in place >24 hours (mean, 3.7 days) in 525 patients. There were no cases of catheter sepsis (0%; 95% confidence interval [CI95], 0%-0.6%), one possible insertion-site infection (0.2%; CI95, 0.004%-0.9%), and seven cases of phlebitis (1.1%; CI95, 0.4%-2.3%). Catheter colonization occurred in 92 (26%) of 348 catheters cultured. Neither the per-day risk of phlebitis nor of catheter colonization increased significantly with placement >3 days. CONCLUSION: Current guidelines recommend replacement of PIV catheters in adults within 2 to 3 days; no recommendations are made for children. Our findings and those of others indicate that the overall risk of PIV catheter complications in children is extremely low and would not be reduced substantially by routine catheter replacement.

Depression in women.

UNLABELLED: Depression is a common and serious psychiatric disorder, more common in women than in men. It can be triggered by abrupt hormonal changes, life events, or nothing at all. It causes enormous debility and significant mortality, and it costs the American economy hundreds of millions of dollars a year. Depression can be readily diagnosed and treated, but, more often than not, it is neither diagnosed nor effectively treated in the primary care setting. The stigma of mental illness and misconceptions about depression in particular, hinder recognition. The signs and symptoms of clinical depression as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, are valid and reliable. Both psychotherapeutic and psychopharmacologic treatments are effective. The obstetrician/gynecologist plays a crucial role in identifying depression, helping the patient, and sometimes her family, to understand the nature of the problem, suggesting treatment, and facilitating either referral or treatment within the Ob-Gyn setting. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to understand the stigmata and misconceptions associated with a depression, to be aware of the various etiologies of depression and typical and atypical presentations, as well as the various management strategies for depression, and have a better understanding of which patients should be referred.

Psychiatry, the law, and public affairs.

The law is a public affair. The involvement of psychiatrists and psychiatry in legal and judicial proceedings themselves, not to mention the ever-increasing media commentary, is an opportunity to educate the public, but it also entails the very real risk of compounding public misinformation and misgivings about our field. The American Psychiatric Association has both a professional staff Division of Public Affairs and a membership component, the Joint Commission on Public Affairs. Staff and members field queries from the public and the media, plan educational campaigns in collaboration with advocacy organizations, prepare and distribute fact sheets, media kits, and issue kits for members, brochures for the lay reader, booklets for important audiences including clergy, educators, and legislators, and many other resources. Given their critical influence on the lay-person's image and understanding of psychiatry, the participation of forensic psychiatrists in the public affairs activities of our major professional organization is not only welcome, but vital.

Abortion: social context, psychodynamic implications.

PIP: A case report presented by a US psychoanalyst suggests that the trauma of reproductive loss, such as miscarriage of a wanted pregnancy, can trigger suppressed feelings associated with an earlier induced abortion. The patient entered psychoanalysis when she was a 24-year-old graduate student to address relationship problems. As a 19-year-old college student, she became pregnant and chose to have an induced abortion because she was not ready to make a permanent commitment to her boyfriend or to provide properly for a child. She reported feeling grateful at the time that motherhood was not imposed on women as punishment for being sexually active and that childbearing was a free choice. The patient married during psychoanalytic treatment and decided she wanted to have a child. She experienced a hydatiform molar pregnancy, following which memories of the abortion 10 years earlier began to surface in the analysis for the first time. Her grief about the recent pregnancy loss melded with emotions about the earlier abortion. Through the analytic relationship, the patient was able to experience and express this sadness. This case underscores the need for psychotherapists to ensure that the political importance of protecting women's right to reproductive choice does not obstruct the exploration of complex emotions that may be associated with a voluntary induced abortion.^ieng

Psychosocial aspects of induced abortion.

PIP: US anti-abortion groups have used misinformation on the long-term psychological impact of induced abortion to advance their position. This article reviews the available research evidence on the definition, history, cultural context, and emotional and psychiatric sequelae of induced abortion. Notable has been a confusion of normative, transient reactions to unintended pregnancy and abortion (e.g., guilt, depression, anxiety) with serious mental disorders. Studies of the psychiatric aspects of abortion have been limited by methodological problems such as the impossibility of randomly assigning women to study and control groups, resistance to follow-up, and confounding variables. Among the factors that may impact on an unintended pregnancy and the decision to abort are ongoing or past psychiatric illness, poverty, social chaos, youth and immaturity, abandonment issues, ongoing domestic responsibilities, rape and incest, domestic violence, religion, and contraceptive failure. Among the risk factors for postabortion psychosocial difficulties are previous or concurrent psychiatric illness, coercion to abort, genetic or medical indications, lack of social supports, ambivalence, and increasing length of gestation. Overall, the literature indicates that serious psychiatric illness is at least 8 times more common among postpartum than among postabortion women. Abortion center staff should acknowledge that the termination of a pregnancy may be experienced as a loss even when it is a voluntary choice. Referrals should be offered to women who show great emotional distress, have had several previous abortions, or request psychiatric consultation.^ieng